MASSHEALTH PRESCRIPTION AND MEDICAL NECESSITY REVIEW FORM 
FOR GAIT TRAINERS 

THE COMMONWEALTH OF MASSACHUSETTS 
Executive Office of Health and Human Services 
Sections 1, 2, 3, and 4 must be completed by the provider of DME or the prescribing provider. Section 5 must be completed by the provider 
of DME. Sections 6 and 7 must be filled out by the prescribing provider. 

SECTION 1 

Member Name Date of Delivery / / 
Address Telephone No. 
MassHealth ID No. Date of Birth / / Gender Height Weight 
Primary ICD-9 Code Description 
Secondary ICD-9 Code Description 
SECTION 2 
Prescribing Provider’s Name NPI No. 
Address 
Telephone No. Fax No. 
SECTION 3 
Name of Provider of DME NPI No. 
Address 
Telephone No. Fax No. 
SECTION 4 


Description of Item(s) Being Requested HCPCS Code Modifier 

1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
SECTION 5 

Provider of DME Attestation, Signature, and Date 

I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has 
been reviewed and signed by me, and it is true, accurate and complete, to the best of my knowledge. I also certify that I am the provider or, 
in the case of a legal entity, duly authorized to act on behalf of the provider. I understand that I may be subject to civil penalties or criminal 
prosecution for any falsification, omission, or concealment of any material contained herein. 

Signature of provider of DME (Signature and date stamps, or the signature of anyone other than the provider or a person 
legally authorized to sign on behalf of a legal entity, are not acceptable.): 

Printed legal name of provider: Date / / 

Printed legal name of individual signing (if the provider is a legal entity) 

MNR-GT (07/11) continued on back 



Member Name: 

SECTION 6 

Section 6 must be completed by the member’s prescribing provider or the provider’s staff. Please attach any pertinent information (for 
example, lab tests, medical history and physical examination, or clinical notes). 

1) Is the member able to stand upright with assistance and have some lower-extremity and trunk strength? . . . . . . . . . . . . . . . . . . Yes No 
2) Is the member unable to ambulate due to conditions such as, but not limited to, neuromuscular or congenital disorders, 
including acquired skeletal abnormalities?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
3) Does the member have lower-extremity contractures that preclude ambulation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
4) Does the member have adequate range of motion (ROM) to support mobility?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
5) Is the alignment of the member’s lower extremity such that the foot and ankle can tolerate a standing position 
as well as independent reciprocal movement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
6) Does the member have complete paralysis of the hips and legs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
7) Does the member have improvement in mobility, weight bearing, ambulation, function, or physiologic symptoms, 
or has the member maintained status with the use of the selected gait trainer (for example, used in inpatient or outpatient setting) 
and is able to follow a home therapy program incorporating the use of the gait trainer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
8) Does the member have a home therapy plan outlining the use of the requested gait trainer and affirming that there is a caretaker 
who can appropriately supervise the use of the gait trainer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
9) Does the member have the cognitive ability to functionally ambulate with the support of a gait trainer?. . . . . . . . . . . . . . . . . . . . Yes No 

SECTION 7 

Prescribing Provider’s Attestation, Signature and Date 

I certify under the pains and penalties of perjury that I am the prescribing provider identified in section 2 of this form. Any attached 
statement on my letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) 
on this form is true, accurate and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal 
prosecution for any falsification, omission, or concealment of any material contained herein. 

Note: Signature and date stamps or the signature of anyone other than the prescribing provider are not acceptable. 

Prescribing provider’s signature (Signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable.): 

Check applicable credentials: 


MD 
NP 
PA 
Printed name of prescribing provider: Date / / 


Instructions for Completing the MassHealth Prescription and Medical Necessity Review Form for Gait Trainers 

Sections 1, 2, 3, and 4 may be completed by the provider of DME or the prescribing provider. Section 5 must be completed by the provider of DME. 

Instructions for the 
Use of this Form 
Providers of DME are instructed to use this form when obtaining a Prescription and Letter of Medical Necessity from 
the member’s prescribing provider for gait trainers, and as an attachment to a prior-authorization (PA) request for 
gait trainers. Providers of DME are responsible for ensuring compliance with applicable MassHealth regulations and 
guidelines when using this form. MassHealth reserves the right not to accept the form if it is completed improperly, 
or if the provider has failed to meet applicable MassHealth regulations, requirements, and guidelines, including 
without limitation medical necessity requirements. Please refer to the MassHealth Guidelines for Medical Necessity 
Determination for Gait Trainers for further information about required clinical documentation and information that 
must be submitted for PA requests for gait trainers. A copy of this completed form (including all attachments and 
supporting documentation) must be maintained in the member’s medical record at the prescribing provider’s office 
and at the provider of DME’s office. 
Section 1 Enter the date of delivery that the items were dispensed to the member. (To be completed once the service has been 
provided.) The date of delivery on this form must match the date on the delivery slip required under 130 CMR 409.000 
and 450.000. Enter the member’s name, MassHealth member ID, address (including apartment number if applicable), 
telephone, date of birth, gender, height, weight, and applicable ICD-9 diagnosis code(s) with their descriptions. 
Section 2 Enter the prescribing provider’s name, NPI, address, and telephone, and fax numbers. 
Section 3 Enter the name of provider of DME, NPI, address, and telephone, and fax numbers. 
Section 4 Enter the HCPCS code(s), the modifier(s), and a description of the gait trainer. 
Section 5 Providers of DME must sign the form and enter the date the form was completed. By signing the form, the provider is 
certifying the information above the signature line. Note: Signature and date stamps, or the signature of anyone 
other than the provider of DME or a person legally authorized to sign on behalf of a legal entity (if provider of 
DME is a legal entity), are not acceptable. 
Sections 6 and 7 must be completed by the prescribing provider. 
Section 6 The member’s prescribing provider or the provider’s staff must complete the medical justification for the requested 
product(s). This section must be completed, and applicable supporting documentation must be attached. 
Section 7 The member’s prescribing provider listed in Section 2 of this form must review all information completed on and 
attached to this form, and must sign and date the form. By signing the form, the prescribing provider is certifying the 
information above the signature line. The form must be signed by the member’s prescribing provider, who must 
be either the member’s physician (MD), nurse practitioner (NP), or physician assistant (PA). The prescribing 
provider must check the applicable credential(s). 

If you have any questions about how to complete this form, please contact MassHealth Customer Service at 1-800-841-2900.